Kaiser Slides on People-Who are Dually Eligible for Medicare-and-medicaid-medicaid-070713
Dual eligible beneficiaries comprise 20% of the Medicare population and 15% of the Medicaid population in 2008 Medicare Dual Eligible Medicaid 37 million Beneficiaries 51 million 9 million Total Medicare beneficiaries: 46 million Total Medicaid beneficiaries: 60 millionSOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and theUninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.
Medicare is the primary payer of medical care for dual eligible beneficiaries Distribution of Medicare Spending for Dual Eligible Beneficiaries in Medicare FFS by Medicare Service, 2008 • National program for Inpatient individuals age 65+ and Hospital younger adults with disabilities (on SSDI) Hospice 34% 4% • Eligibility tied to work Home history but not tied to Health 5% income or health status Providers • Covers medical care, 20% SNF 8% prescription drugs, and is the primary source of Drug medical insurance for dual Subsidies 13% eligible beneficiaries Outpatient 16% • Financial obligations can be steep for beneficiaries Average Per Capita Medicare FFS Spending: $13,805NOTE: Medicare Advantage spending excluded from this analysis.SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008
Medicaid supplements Medicare for dual eligible beneficiaries Distribution of Medicaid Spending for Dual Eligible Beneficiaries by Service, 2008 Medicaid Medicare • Federal-state partnership premiums with states operating 9% programs for low-income 69% families, disabled & elderly Long Term Medicare • Eligibility tied to income, Care acute care age and disability, varies 16% cost- by state sharing • Pays for Medicare premiums, cost-sharing 5% Acute care and other benefits not covered by Medicare • Primary payer for long- 1% term care Prescription Drugs Average Per Capita Medicaid Spending: $16,087NOTES: Home health and dental services comprise less than 1% of Medicaid spending. Medicare premiums paid by Medicaid also includes cost-sharing for Qualified Medicare Beneficiaries only.SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.
Dual eligible beneficiaries are a diverse population Age 85+ 4 or more 14% Chronic Age 75-84 No Mental Conditions Impairments 35% 21% 51% Community 3 Chronic Age 65-74 Conditions 87% 26% 20% 2 Chronic Conditions Mental 20% Under Age 65 Impairment 0 or 1 39% 49% Chronic Facility Conditions 13% 25% Age Type of Mental Number of Residence Impairments Chronic ConditionsNOTE: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation.SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008
Dual eligible beneficiaries are poorer than other Medicare beneficiaries Share of Medicare beneficiaries who are:Income below 150% FPL 86% (<$15,600 individuals/ <$21,000 couples) 22% 61% Female 53% Dual eligible 20% beneficiaries African American 7% All other Medicare beneficiaries 17% Hispanic 6%SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
Dual eligible beneficiaries are sicker than other Medicare beneficiaries Share of Medicare beneficiaries with: Cognitively or 58% Mentally Impaired 25% 55%3+ Chronic Conditions 44% 50% In Fair or Poor Health 22% Dual eligible beneficiaries 44%Functionally Impaired All other Medicare 26% beneficiariesSOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
Dual eligible beneficiaries use more health services Share of Medicare beneficiaries with: 26% 1+ Hospital Stay 18% 1+ Emergency 17% Room Visit 12% Dual eligible 1+ Skilled Nursing 9% beneficiaries Facility Stay All other Medicare 4% beneficiariesNOTE: Excludes Medicare Advantage enrollees.SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
Dual eligible beneficiaries account for a disproportionate share of Medicare and Medicaid spending, 2008 Dual Eligible Beneficiaries as a Share Dual Eligible Beneficiaries as a Share of Medicare Population and Spending of Medicaid Population and Spending 61% 69% 80% 85% 39% 31% 20% 15% Total Population: Total Spending: Total Population: Total Spending: 46 Million $424 Billion 60 Million $330 Billion Medicare MedicaidSOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission onMedicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.
Medicare spending was more than $40,000 for 8% and less than $2,500 for 16% of the dual eligible population Distribution of Medicare spending for Dual Eligible Beneficiaries, 2008: $15,000- $20,000 $10,000- $15,000 13% $5,000-$10,000 26% Average Spending = $14,169 Median Spending = $7,036SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.
Dual eligible beneficiaries account for a substantial share of Medicaid spending Medicaid Enrollment, 2009 Medicaid Spending, 2009 Premiums 3% Medicare Acute 7% Other Adults Aged & Other Acute 26% Other Aged Disabled 2% & Disabled Spending 10% 28% Duals Duals 15% Long- Spending Children Term Care 38% Children & Adult 25% 49% Spending 34% Prescribed Drugs 0.4% Total = 63 Million Total = $359 BillionSOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012. MSIS FY2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64.
Few dual eligible beneficiaries are high spenders under both Medicare and Medicaid 0.8 0.1 Top 10% of Medicare 0.8 $80.8 Spenders; Spending Above $44,348 $12.3 Top 10% of Spenders in Both Medicare and Medicaid $67.8 Top 10% of Medicaid Spenders; Spending Above 7.2 $45,180 Not a Top 10% Spender in Either Program $104.8 Total Beneficiaries= 8.9 million Total Spending= $265.7 billionSOURCE: KCMU/ Urban Institute analysis of MSIS-MCBS 2007.
Spending by service varies among high-cost dual eligible beneficiaries by program Top 10% Medicare Spenders Top 10% Medicaid Spenders (in billions) (in billions) Long-Term Care, $8.3 9% Sub-Acute Acute Care, $11.7 Care, 13% $18.4 23% Sub- Acute Long- Care, $2.8 Acute Care, Term 4% $73.1 Care, 78% $58.9 74% Total = $93.1 billion Total = $80.1 billionNOTE: Top 10% Medicare spenders = Medicare spending greater than $44,348, includes Medicaid spending on Medicare high-spenders.Top 10% Medicaid spenders = Medicaid spending greater than $45,180, includes Medicare spending on Medicaid high-spenders.SOURCE: KCMU/Urban Institute analysis of MSIS-MCBS 2007.
Share of Dual Eligible Beneficiaries in Medicare Advantage and Medicaid Managed Care Plans, 2000-2008 Share of Duals in Medicare Advantage Plans Share of Duals in Comprehensive Medicaid Managed Care Plans 20% 17% 14% 9% 10% 9% 9% 9% 7% 8% 7% 7% 7% 6% 2000 2001 2002 2003 2004 2005 2006 2007 2008NOTES: Data exclude dual eligibles living in Puerto Rico and other territories. Medicaid manage care data include duals in commercial andMedicaid managed care organizations (comprehensive risk), health insuring organizations, and PACE plans. Information on dual enrollment inMedicaid comprehensive managed care plans was not available at the time of publication for years prior to 2004.SOURCE: Gold M., Jacobson G, and Garfield R. analysis of the CMS MCBS Cost and Use File, 2000-2008, CMS Medicaid Managed Care Enrollmentreports, 2004-2008, and Medicaid Statistical Information System 2004-2008., Health Affairs 2012.
Share of Dual Eligible Beneficiaries Enrolled in Managed Care, by State, 2010NOTE: National average was 12.0% enrolled in Medicare Dual-Special Needs Plan (DSNP )and 9.3% enrolled in comprehensive Medicaid managedcare (MMC. )SOURCE: Gold M, Jacobson G, and Garfield R. analysis of public Medicare and Medicaid data files from the Center for Medicare and MedicaidServices, Health Affairs, 2012.
26 states are moving forward with proposals to participate in demonstration projects, May 2012 WA VT ME MT ND NH MN OR WI NY MA ID SD MI WY CT*RI PA NJ IA* NE OH DE NV IL IN MD UT WV VA CO* MO* DC KS KY CA NC* TN OK* AR SC AZ NM MS AL GA TX LA FL AK HI Proposed 2013 Start Date (14 states) Proposed 2014 Start Date (12 states) Not participating in demonstration (24 states and DC)* CO, CT, IA, MO, NC, and OK are proposing managed FFS models. All others have proposed capitated models.NOTE: MO has proposed a 2012 start date.SOURCE: Correspondence with CMS Medicare-Medicaid Coordination Office, May 2012
Key considerations for testing new models of managed care for dual eligible beneficiaries • The current landscape offers room for improvement The current system is fragmented; coordination will help to improve care • One size will not fit all Various approaches are needed to address each subgroup’s unique needs • Building expertise and plan capacity takes time Few health plans and states have experience managing both populations • Proceed with caution Infrastructure needs to be in place; transitions are difficult • Don’t count your savings before they are hatched Many are laying claim to savings, few results to date have shown cost savings • Accountability matters: who will be in charge? Oversight needs to protect beneficiary rights and evaluation needs to be dynamicSOURCE: Dx For A Careful Approach To Moving Dual Eligible Beneficiaries Into Managed Care Plans. Health Affairs, June 2012.http://content.healthaffairs.org/content/31/6/1186.full?ijkey=A0Vp04z5lZzbY&keytype=ref&siteid=healthaff